Diagnosis and Management of UTI s in Care Home Settings. To Dip or Not to Dip?

Transcription

1 Diagnosis and Management of UTI s in Care Home Settings To Dip or Not to Dip? 1

2 Key Summary Points: Treat the patient NOT the urine In people 65 years, asymptomatic bacteriuria is common. Treating does not reduce mortality or prevent symptomatic episodes, but does increase side-effects and antibiotic resistance. Ensure care home have faxed across the CCG UTI Assessment Tool Diagnosis: Follow UTI treatment algorithm UTI is likely if: A patient has a fever >38 C or 1.5 C above baseline twice in 12hours AND >1 symptom as per below Residents without a Urinary catheter. At least 1 of: Resident with a urinary Catheter. At least 1 of: Dysuria Rigors Urgency Frank haematuria Frequency Flank or suprapubic pain New or worsening urinary incontinence New onset or worsening of pre-existing delirium or agitation Do Not routinely dip urine samples in patients > 65 years. Rigors New costovertebral tenderness New onset or worsening of pre-existing delirium or agitation NEVER use dipstick testing to diagnose UTI in catheterised patients. Urine Cultures: In all men with symptoms of UTI a urine sample should be taken for culture. Do not send urine for culture in asymptomatic elderly with positive dipsticks Only sample if: two signs of infection, especially dysuria, pyrexia >38 o C, new onset of delirium or new incontinence Laboratory testing for culture and sensitivity should be performed in: Suspected pyelonephritis Suspected UTI in men Catheterised patients: only if features of systemic infection, Failed antibiotic treatment, persistent symptoms or recurrent UTI Abnormalities of the genitourinary tract Renal impairment (egfr < 30ml/min or significant renal tract abnormality) Treatment options for women >65 years and ALL Men: Do not treat women 65 years or over with asymptomatic bacteriuria with an antibiotic. Do not treat catheterised patients with asymptomatic bacteriuria with an antibiotic. Do not routinely prescribe antibiotic prophylaxis to prevent symptomatic UTI in patients with catheters Antibiotic Dose Duration First Line Nitrofurantoin MR 100mg BD or 50mg QDS (non MR) Please refer to Second Line Trimethoprim 200mg BD PAN Mersey Renal Impairment (egfr <45ml/min) If Penicillin allergic Pivmecillinam or Cefalexin 400mg STAT then 200mg TDS 500mg TDS Guidance whilst under review 2

3 SIGN 88 Managing suspected UTI in older people 3

4 Why is this important Prudent antibiotic prescribing is a key component of the UK s action plans for reducing antimicrobial resistance. This year s Quality Premium measure consists of three parts: Part a) Reducing gram negative blood stream infections (BSI) across the whole health economy by 10% in 2017/18. Part b) Reduction of inappropriate antibiotic prescribing for urinary tract Infections (UTI) in primary care. A 10% reduction (or greater) in the Trimethoprim: Nitrofurantoin prescribing ratio based on CCG baseline data and a 10% reduction or greater in the number of trimethoprim items prescribed to patients aged 70 years or greater on baseline data. Part c) Sustained reduction of inappropriate prescribing in primary care. Unnecessary antibiotic treatment of asymptomatic bacteriuria is associated with significantly increased risk of clinical adverse events including the development of antibiotic-resistant UTIs In patients with an indwelling urethral catheter, antibiotics do not generally eradicate asymptomatic bacteriuria Particular care should be taken when prescribing nitrofurantoin to elderly patients, who may be at increased risk of toxicity if egfr <45ml/min There is no robust evidence to support leucocyte esterase or nitrite testing in elderly institutionalised patients, this practice is strongly discouraged as a stand-alone diagnostic tool. The Secretary of State for Health has launched an important ambition to reduce healthcare associated Gram-negative bloodstream infections by 50% by 2021 and reduce inappropriate prescribing by 50% by Gram-negative bloodstream infections are believed to have contributed to approximately 5,500 NHS patient deaths in The initial focus is on reducing Escherichia coli bloodstream infections because they represent 55% of all Gram-negative bloodstream infections. Approximately three-quarters of E. coli BSIs occur before people are admitted to hospital. Reduction therefore requires a whole health economy approach. The importance of, and challenges in, reducing E.coli BSI are clearly outlined in the enhanced sentinel surveillance programme which showed that the most common source of infection is the urogenital tract at 51.2%. Therefore targeting urinary tract infections could have a significant impact in reducing the number of healthcare associated infections. The challenge will be working across the health and social care system to reduce these infections. Lower Urinary tract infection Diagnosis and Management This protocol is developed for men and women aged 65 years or over with suspected lower urinary tract infection, to aid implementation of the To Dip or Not to Dip project. This guidance is based on SIGN Guideline 88 and NICE Quality Standards QS90 Guidance for diagnosis and management of urinary tract infections in patients under 65 years of age can be found on the PAN Mersey APC website. 4

5 Introduction Urinary tract infections (UTI s) are the second most common clinical indication for empirical antimicrobial treatment in primary and secondary care, accounting for 1-3% of all GP consultations a year. Subsequently urine samples constitute the largest single category of specimens examined in most medical microbiology laboratories. UTIs are a cause of considerable anxiety for patients, relatives of elderly people and health care workers alike. They complicate co-morbidity and long term conditions, cause discomfort and confusion in older people, predispose them to falls and can lead to hospital admission. Frailty combined with 50% less total body water content, puts older people at greater risk of dehydration and delirium. This combined with poor hydration and the use of diuretics puts them in a higher risk group for UTIs. The diagnosis of UTI is challenging in elderly patients, they are often unable to provide a history of acute urinary symptoms and are more likely to have asymptomatic bacteriuria as they get older. The prevalence of bacteriuria may be so high that urine culture ceases to be a reliable diagnostic test. Consequently elderly institutionalised patients frequently receive unnecessary antibiotic treatment for asymptomatic bacteriuria despite clear evidence of adverse effects with no compensating clinical benefit Existing evidence based guidelines tend to focus on issues of antibiotic treatment (drug selection, dose, duration and route of administration) with less emphasis on clinical diagnosis. For patients with symptoms of urinary tract infection and bacteriuria, the main aim of treatment is symptomatic relief. Secondary outcomes are adverse effects of treatment or recurrence of symptoms. For asymptomatic patients the main outcome from treatment is prevention of future symptomatic episodes. Unnecessary use of tests and antibiotic treatment may be minimised by developing simple decision rules, which is the prime objective of these guideline Decision Rules 1. Urine dipsticks ** No longer recommended in patients 65 years ** Due to the presence of asymptomatic bacteriuria dipstick testing to determine if leucocyte esterase and nitrites are present becomes unreliable in the > 65 year old population, and should be used with careful discretion to guide treatment decisions. Urine dipsticks must never be used in catheterised patients. After catheterisation there will always be a degree of inflammation and therefore protein and/or bacteria in the urine, which is physiological and does not need treatment, unless symptoms are present. 5

6 2. Signs and symptoms In elderly patients diagnosis of UTI should be based on a full clinical assessment, including vital signs A UTI is likely if: A patient has a fever >38 C or 1.5 C above baseline twice in 12hours AND >1 symptom as per below Residents without a Urinary catheter. At least 1 of: Resident with a urinary Catheter. At least 1 of: Dysuria Rigors Urgency Frank haematuria Frequency Flank or suprapubic pain New or worsening urinary incontinence New onset or worsening of pre-existing delirium or agitation Rigors New costovertebral tenderness New onset or worsening of pre-existing delirium or agitation 3. Women > 65 years The prevalence of asymptomatic bacteriuria is so high, up to 50% in older women living in long term care, that it does not necessarily indicate acute illness and is not, on its own, an indication for treatment. Treating asymptomatic bacteriuria does not reduce mortality or significantly reduce symptomatic episodes but considerably increases the risk of adverse events, such as rashes and gastrointestinal symptoms. In cases of recurrent infection it is essential that treatment is guided by a mid-stream urine sample. 4. Adult Men (Any age) Urinary tract infections in men are generally viewed as complicated because they result from an anatomic or functional anomaly of the genitourinary tract. Conditions like prostatitis and epididymitis should be considered in the differential diagnosis of men with acute dysuria or frequency and appropriate diagnostic tests should be considered. At least 50% of men with recurrent UTI and over 90% of men with febrile UTI have prostate involvement, which may lead to complications such as prostatic abscess or chronic bacterial prostatitis. There is no evidence to suggest the best method of diagnosing bacterial UTI in men. Evidence from studies of women cannot be extrapolated. All men with symptoms of UTI a urine sample should be taken for culture. Urine microscopy should not be undertaken in clinical settings in primary or secondary care. Patients with a history of fever or back pain the possibility of upper UTI should be considered. Do not routinely check PSA this will be raised in UTI. A seven day course of antibiotics, as per the formulary, may be considered for those with symptoms of uncomplicated lower UTI. Treat bacterial UTI empirically in men with symptoms suggestive of prostatitis for up to 4 weeks. Refer men for urological investigation if they have symptoms of upper urinary tract infection, fail to respond to appropriate antibiotics or have recurrent UTI. 6

7 5. Catheterised Patients Facts: Between 2% and 7% of patients with indwelling urethral catheters acquire bacteriuria each day, even with the application of best practice for insertion and care of the urinary catheter. All patients with a long term indwelling catheter are bacteriuric, often with two or more organisms. The catheter provides a focus for bacterial biofilm formation. The majority of data comes from studies in elderly patients with long term indwelling catheters. Duration of catheterisation is strongly associated with the risk of infection. The longer the catheter is in place the greater the likelihood of infection. Intermittent catheterisation is associated with a lower incidence of asymptomatic bacteriuria. The presence of a short- or long term indwelling catheter is associated with a greater incidence of fever of urinary tract origin. Fever without any localising signs is a common occurrence in catheterised patients and urinary tract infection accounts for about a third of these episodes. In patients with short-or long term catheters fever is associated with a higher occurrence of local urinary tract and systemic complications such as bacteraemia. Although mortality appears to be higher in patients with long term indwelling catheters, there is no causative link with catheterisation or urinary tract infection. Urinary tract infection is the most common hospital acquired infection in the UK, accounting for 23% of all infections and the majority of these are associated with catheters. Catheter-associated UTI is the source for 8% of hospital acquired bacteraemia. In clinical practice: In catheterised patients; fever, the consistent presence of bacteriuria, and the variable presence of a broad range of other associated clinical manifestations (new onset confusion, renal angle tenderness or suprapubic pain, chills/rigors etc) makes the diagnosis of symptomatic UTI difficult. Recommendations: Consider continued need for catheterisation A clinical algorithm for suspected UTI in catheterised and non-catheterised residents in nursing homes suggests that the presence of one of the following symptoms should stimulate antibiotic therapy new costovertebral tenderness rigors or fever >30 C or 1.5 C above baseline on two occasions during 12 hours new onset delirium No particular collection of symptoms or clinical signs, for example, fever or chills, new flank or suprapubic tenderness, change in character of urine or worsening of mental or functional status, appears to increase the likelihood of a symptomatic urinary tract infection in catheterised patients. Do not rely on classical clinical symptoms or signs for predicting the likelihood of symptomatic UTI in catheterised patients. Only send urine samples for laboratory culture if the patient has clinical sepsis, not because the appearance or smell of the urine suggests that bacteriuria is present. Dipsticks must NEVER be used to diagnose infection in catheterised patients Catheter samples of urine must ONLY be taken by staff who have been trained to do this. Do not give antibiotics prophylactically There is no evidence base to use antibiotics at routine catheter changes unless prosthesis is in place 7

8 How to interpret a urine culture result Usually indicates UTI in patients with urinary symptoms. Higher counts have even higher positive predictive value. Single organism >10 4 colony forming units (CFU)/mL >10 5 mixed growth with one predominant organism Escherichia coli or Staphylococcus saprophyticus >10 3 CFU/mL White Cells >10 4 /ml are considered to represent inflammation No white cells present indicates no inflammation and reduces culture significance Sterile Pyuria In sterile pyuria, consider Chlamydia trachomatis (especially if years), other vaginal infections, other non-culturable organisms, including TB or renal pathology Epithelial cells/mixed growth Presence indicates perineal contamination, which reduces significance of culture Red Cells: May be present in UTI; refer patients with persistent haematuria post-uti Lab microscopy for red cells is less accurate than dipstick due to red cell lysis in transport 8

9 Appendix 1 NICE quality statements Quality Statement 1 Adults aged 65 years and over have a full clinical assessment before diagnosis of urinary tract infection is made Rationale The accuracy of dipstick testing in adults aged 65 years and over can vary. It is therefore important that factors other than results of dipstick testing are taken into consideration when diagnosing urinary tract infections in older people to ensure appropriate management and avoid unnecessary use of antibiotics Quality Statement 2 Healthcare professionals do not use dipstick testing to diagnose urinary tract infections in adults with urinary catheters Rationale Dipstick testing is not an effective method for detecting urinary tract infections in catheterised adults. This is because there is no relationship between the level of pyuria and infection in people with indwelling catheters (the presence of the catheter invariably induces pyuria without the presence of infection). To ensure that urinary tract infections are diagnosed accurately and to avoid false positive results, dipstick testing should not be used Quality Statement 5 Healthcare professionals do not prescribe antibiotics to treat asymptomatic bacteriuria in adults with catheters or pregnant women. Rationale Antibiotics are not effective for treating asymptomatic bacteriuria in adults 65 years or over with or without catheters. Unnecessary treatment with antibiotics can also increase the resistance of bacteria that cause urinary tract infections, making antibiotics less effective for future use. 9

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